Community-based treatment of advanced HIV disease: Introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy)

Department of Social Medicine, Harvard Medical School, Boston, MA, USA.
Bulletin of the World Health Organisation (Impact Factor: 5.09). 02/2001; 79(12):1145-51. DOI: 10.1590/S0042-96862001001200011
Source: PubMed


In 2000, acquired immunodeficiency syndrome (AIDS) overtook tuberculosis (TB) as the world's leading infectious cause of adult deaths. In affluent countries, however, AIDS mortality has dropped sharply, largely because of the use of highly active antiretroviral therapy (HAART). Antiretroviral agents are not yet considered essential medications by international public health experts and are not widely used in the poor countries where human immunodeficiency virus (HIV) takes its greatest toll. Arguments against the use of HAART have mainly been based on the high cost of medications and the lack of the infrastructure necessary for using them wisely. We re- examine these arguments in the setting of rising AIDS mortality in developing countries and falling drug prices, and describe a small community-based treatment programme based on lessons gained in TB control. With the collaboration of Haitian community health workers experienced in the delivery of home-based and directly observed treatment for TB, an AIDS-prevention project was expanded to deliver HAART to a subset of HIV patients deemed most likely to benefit. The inclusion criteria and preliminary results are presented. We conclude that directly observed therapy (DOT) with HAART, "DOT-HAART", can be delivered effectively in poor settings if there is an uninterrupted supply of high-quality drugs.

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    • "Community based TB control also offers many lessons for the control of HIV epidemic. With the emergence of HIV and consequent TB resurgence, a comprehensive and equitable strategy is needed to stem the worsening double burden of these two infections in poor countries [56]. "
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    ABSTRACT: In 2012, an estimated 8.6 million people developed tuberculosis (TB) and 1.3 million died from the disease. With its recent resurgence with the human immunodeficiency virus (HIV); TB prevention and management has become further challenging. We systematically evaluated the effectiveness of community based interventions (CBI) for the prevention and treatment of TB and a total of 41 studies were identified for inclusion. Findings suggest that CBI for TB prevention and case detection showed significant increase in TB detection rates (RR: 3.1, 95% CI: 2.92, 3.28) with non-significant impact on TB incidence. CBI for treating patients with active TB showed an overall improvement in treatment success rates (RR: 1.09, 95% CI: 1.07, 1.11) and evidence from a single study suggests significant reduction in relapse rate (RR: 0.26, 95% CI: 0.18, 0.39). The results were consistent for various study design and delivery mechanism. Qualitative synthesis suggests that community based TB treatment delivery through community health workers (CHW) not only improved access and service utilization but also contributed to capacity building and improving the routine TB recording and reporting systems. CBI coupled with the DOTS strategy seem to be an effective approach, however there is a need to evaluate various community-based integrated delivery models for relative effectiveness.
    Infectious Diseases of Poverty 08/2014; 3(1):27. DOI:10.1186/2049-9957-3-27 · 4.11 Impact Factor
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    • "The reason for this difference may be that Ford and colleagues included estimates from the post intervention period; during which the efficacy of the intervention may have waned [13], unlike in this meta-analysis where the duration considered for the analysis was shorter .i.e., 12 months from starting ART. If the effects of directly observed ART intervention are not durable .i.e., once people graduate from the directly observed ART intervention there is no benefit on adherence to ART, there may be need for directly observed ART interventions that are repetitive [45,46] or ongoing [47]. "
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    BMC Public Health 03/2014; 14(1):239. DOI:10.1186/1471-2458-14-239 · 2.26 Impact Factor
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    • "It forces them to think of provision in new ways, reaching beyond healthcare facilities to communities. As they attend to PLWH, health professionals have rediscovered the role of the community system in disease prevention and management, as stated in the Alma Ata Declaration and in subsequent documents on primary healthcare and health promotion [23-25]. In many church-based healthcare centers, lay community workers are trained by diocesan healthcare coordinators to perform some clinical tasks. "
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    ABSTRACT: Universal access to antiretroviral treatment (ART) in Chad was officially declared in December 2006. This presidential initiative was and is still funded 100% by the country's budget and external donors' financial support. Many factors have triggered the spread of AIDS. Some of these factors include the existence of norms and beliefs that create or increase exposure, the low-level education that precludes access to health information, social unrest, and population migration to areas of high economic opportunities and gender-based discrimination. Social forces that influence the distribution of dimensions of well-being and shape risks for infection also determine the persistence of access barriers to ART. The universal access policy is quite revolutionary but should be informed by the systemic barriers to access so as to promote equity. It is not enough to distribute ARVs and provide health services when health systems is poorly organized and managed. Comprehensive access to ART raises many organizational, ethical and policy problems that need to be solved to achieve equity in access. This paper argues that the persistence of access barriers is due to a weak health system and a poor public health leadership. AIDS has challenged health systems in a manner that is essentially different from other health problems.
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